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Program Integrity Unit

Staff in the Program Integrity Unit (PI) monitor financial claims for NH's Medicaid plan. PI reviews all provider claims for fraud, waste or abuse. The unit also recovers overpayments. If there appears to be a case of fraud, it is referred to the Attorney General's office for further review. PI also conducts reviews to determine if recipients are inappropriately using certain types of medications.

PI provides management of the Quality Improvement Organization (QIO) contract, which is responsible for the review of all hospital admissions for medical necessity and quality of care.

Specifics activities include:

  • On-site audits and desk reviews of provider bills and medical records;
  • Monitor the Quality Inpatient Organization Contract for in-patient claims;
  • Review of pended provider claims;
  • Verification of recipient medical services;
  • Monitor provider sanctions received by Medical Boards;
  • Make recommendations for claims processing system modifications;
  • Assess and report on program outcomes and recommend policy and procedure changes as necessary; and
  • Review of new provider enrollment applications as necessary.

Fingerprint-based Criminal Background Check (FCBC)
The Affordable Care Act requires, as a component of provider screening, that certain providers and those with a 5% or more direct or indirect ownership interest in them be considered high risk for fraudulent billing activities and accordingly, be required to undergo a national and state criminal background check, including fingerprinting. (42 U.S.C. 1396a(a)(77); 42 U.S.C. 1396a(kk) and 42 CFR Part 455 Subpart E.) FCBC requirements are set forth in Administrative rule He-W 520. For more information on how this process works please view the PowerPoint presentation and the frequently asked questions (FAQ).

 

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New Hampshire Department of Health and Human Services
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